| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
999 |
989 |
$52K |
| D9430 |
|
1,382 |
1,180 |
$43K |
| D1120 |
Prophylaxis - child |
592 |
590 |
$20K |
| D1110 |
Prophylaxis - adult |
271 |
271 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,288 |
1,279 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
212 |
$11K |
| D0272 |
Bitewings - two radiographic images |
886 |
875 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,916 |
978 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
161 |
$7K |
| D0330 |
Panoramic radiographic image |
121 |
121 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
71 |
71 |
$1K |
| D1320 |
|
39 |
39 |
$552.50 |
| D0601 |
|
35 |
35 |
$0.00 |
| D1310 |
|
39 |
39 |
$0.00 |